thumb sign

thumb sign ( ask patient to clench her thumb in her fist, the thumb should not exceed the ulnar side of the hand in normal subjects)

acromegaly hand

PACES exam, i got an acromegaly case. The stem being " please examine the patient's hands".

By one look at the patient, we are happy to conclude that the patient has acromegaly, the next thing in my mind is what the examiner want me to pick up from the patient's hands with acromegaly.

Possible things to pick up:
1) Carpal Tunnel syndrome
2) Osteoarthritis
3) Pure hand feature of acromegaly

We may easily get a 4 mark if we follow the stem, go accordingly to point out the features that support the diagnosis.
Steps to follow in order for acromegaly patient in the very moment of 2 min before we use up 3 min for presentation.
1) Hand : large spade like hand, doughy hand, sweaty palm, tinel's sign

2) armpit: especially to look for skin tag (most candidate miss it, and we may only get 3 if we miss it)

3) Face: Prominent supraorbital ridge, prognatism, widely-space teeth, macroglossia, increase in skin creases/ wrinkles

4) Visual field assessment -bitemporal hemianopia

5) Lower limb: large foot, osteoarthritis of knee, thicken heel pad

6) complete by mentioning: checking BP, urine for glycosuria, examine for galactoria

Present as such order to make it systematic but the opening sentence must be base on the stem, in this case, "examine the hand"
Eg:
This patient has features of acromegaly. I say so because she has a large doughy, spade like hand. Her palm appeared sweaty. There is evidence of carpal tunnel syndrome as the tinel sign is positive. I found a skin tag over her right axillary area. Her voice appears to be coarse, she has prominent supraorbital ridge, and prognatism. She has macroglossia with widely-space teeth. Her foot appears to be large. Her heel pad is thickened. There is sign of osteoarthritis over her knee joint. There is no evidence of bitemporal hemianopia.

In conclusion, Mdm X has acromegaly. The most likely cause is a macroadenoma. There is sign of active disease in view of presence of sweaty palm, and skin tag. I would like to further assess her cardiovascular system.

These are the questions the examiner asked from me: ( not much time left after my presentation)
1) How do you confirm the diagnosis
Answer: Failure of suppression of GH level to less than 2ng/ml after oral glucose confirm the diagnosis

2) What further test you want to do?
Answer: Localization of pituitary tumour by requesting a MRI of brain

3) What are the treatment?
optimization of cardiovascular risk by strict BP and sugar control, refer eye for Visual field perimetry, definitive treatment: transphenoidal hypophysectomy, medical: somatostatin analogue: Octreotide, GH receptor antagonist: Pegvisomant

That end the session with clear pass from both examiner.
Further possible question:
1) What other source of GH if MRI shows no macroadenoma?
Answer: ectopic growth hormone production, small cell CA lung

2) How do you monitor treatment response?
Answer: insulin like growth factor

3) Do you know of any endocrine adenoma association with acomegaly?
Answer: MEN type 1 -parathyroid hyperplasia, pituitary adenoma, pancreatic tumor
Need to examine calcium level

acromegaly disease is active or not, what is the full answer?

acromegaly disease is active or not, what is the full answer?

sweating, hypertension, glycosuria and headaches will indicate disease activity

Don't miss a scar in hypothyroid patient!

General inspection
** Hoarse voice, response and movements are slow
** Overweight
** Myxoedematous facies as shown in the picture

Check eye for jaundice(?chronic active hepatitis)and pallor (?hemolytic anemia). Don't forget to look for Grave's disease eye signs.

Rub the hair with your fingers to feel for coarse hair.

Check the mouth for macroglossia.

Check the neck for goitre and scar
Don't miss a scar in this case! In PACES, 99.9% of hypothroidism is due to previous total thyroidectomy.

Thyroidectomy scar!
Then, proceed to the hand to count the pulse rate i.e. bradycardia and look for acropachy in Grave's ds.

Test for proximal myopathy over shoulder.

Check for pretibial myxoedema and pedal edema in lower limbs.

Lastly, position the patient in a chair to test the ankle jerk for slow relaxation phase. Remember, this is the most important sign that indicate the patient is clinically hypothyroid!

End your examination by saying that you would complete it by checking CVS, Lung and cerebellar signs.

Learning points:
** Don't miss a scar in hypothyroid patient!
** Always look for Grave's ds signs in hypothroid patient. Remember, the treatment may cause hypothroidism!

Cushing's syndrome

Cushing's syndrome is another popular spot diagnoses in PACES. The candidate is usually asked to "Look at the patient's face".

There are 3 main steps in dealing with this case:

First, be able to recognise all the striking features of Cushing's syndrome.
** Typical moon-face with plethora, hirsutism and acne.
** Truncal obesity with interscapular and supraclavicular fad pads.
** Purple striae over the abdomen, around the shoulders and breasts and thighs.
** Thin skin and easy brusing commonly found over limbs
** Proximal myopathy (shoulders & hips) and spinal tenderness (osteoporosis)

Then, you must always look out for the possible underlying diagnosis as it is not enough for a PACES candidate to get the diagnosis of Cushing’s syndrome only in MRCP.

Lastly, please complete your examination by mentioning that you would like to measure the BP and test the urine for sugar.

Points to remember: The commonest cause is still iatrogenic i.e. secondary to steroid. So, please look for RA hands, gouty arthritis, nephrotic syndrome and etc.

cushing

turners

lobectomy

In upper lobectomy , the lower lobe fills up the space left in the upper lobe thereby pulling up the diaphragm up , hence a raised diaphragm on side of lobectomy and clinical signs ( dullness, reduced vocal resonance) are confined to lower chest zones. The findings are same in lower lobectomy

a scar is a gift!"

a scar is a gift!"

As in this case with a big thoracotomy scar, one could localize the lesion side by the presence of the scar. Then, you should pay attention to the air entry during auscultation.
a. If air entry is reduced, then think of lobectomy and pneumonectomy.
b. If air entry is equal, then think of decortication and bullectomy.

"Which side first?

"Which side first?"

One of the favourite question my friends ask me for respiratoryry station. It's really depend on what you gather from the peripheral examination namely the tracheal position. If the tracheal is deviated, then I would advise you to concentrate on anterior chest first especially the apical region looking for apical fibrosis or collapse.
If the tracheal is central, then ask the permission to proceed with the back. The differentials would include fibrosing alveolitis, bronchiectasis, pleural effusion or consolidation.

lobectomy vspneumonectomy.

The differences:
1. The signs of lobectomy are confined to lobe which is removed. The signs are similar to pleural effusion except it is not stony dull.

2. The signs of pneumonectomy are extensive i.e. involve the whole lung. The side involved would be flatten. It is similar to whole lung collapse.

3. Normally, the tracheal is central in lobectomy except for upper lobe. The tracheal is almost always shifted in pneumonectomy.

dDX of creps and clubbing -
ca. of lung, fibrosing alveolitis, lung abscess

cause for fibroising alveolitis

The respiratory case that I had in UK was rheumatoid lung disease. I got no problem in detecting the clubbing and fine inspiratory crepitations bibasally. But, the outcome was 2/2!

Pitfall: I failed to identify the underlying cause for fibrosing alveolitis. I missed out the obvious sign i.e. Rheumatoid hand changes!

The moral of the story to learn is ALWAYS look for the underlying cause for fibroising alveolitis as cryptogenic fibrosing alveolitis is RARE for PACES!

Face: malar rash (SLE)
telangiectasia, beak nose, microstomia (scleroderma)
facial pigmentation (amiodarone)
heliotrope rash (dermatomyositis)
Hand: RA, sclerodactyly

causes of gynaecomastia

Station 1 : Abdomen - Cirrhosis of liver

Station 1 - Resiratory - Bronchogenic carcinoma

Station 3 : Cardiovascular - Drugs (spironolactone/digoxin)

Station 3 : Neurology - Myotonic dystrophy

Station 5 : Endocrine - Klinefelter's syndrome

I know there are other causes of gynaecomastia

HELICON KIT:

HELICON KIT:
H.Pylori eradicating kit
Each Helicon Kit contains: One Lansoprazole INN 30mg Capsule. Two Amoxicillin BP 500 mg Capsules UPS 500 mg tablet.
Indications: Helicon Kit is indicated in the eradication of H. pylori in active chronic gastritis, duodenal and gastric ulcers.

Mannitol IV

Mannitol IV

Indications & Dosage

INDICATIONS

Mannitol I.V. (Mannitol Injection, USP) is indicated for the following purposes in adults and pediatric patients.

Therapeutic Use

1. Promotion of diuresis in the prevention or treatment of the oliguric phase of acute renal failure before irreversible renal failure becomes established.

2. Reduction of intracranial pressure and brain mass.

3. Reduction of high intraocular pressure when the pressure cannot be lowered by other means.

4. Promotion of urinary excretion of toxic materials.

Diagnostic Use

Measurement of glomerular filtration rate

Reduction of Intracranial Pressure and Brain Mass

Reduction of Intracranial Pressure and Brain Mass: In adults a dose of 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes; pediatric patients 1 to 2 g/kg body weight or 30 to 60 g/m² body surface area over a period of 30 to 60 minutes. In small or debilitated patients, a dose of 500 mg/kg may be sufficient. Careful evaluation must be made of the circulatory and renal reserve prior to and during administration of mannitol at the higher doses and rapid infusion rates. Careful attention must be paid to fluid and electrolyte balance, body weight, and total input and output before and after infusion of mannitol. Evidence of reduced cerebral spinal fluid pressure must be observed within 15 minutes after starting infusion